Social Risk Score, Clinical Decision Support Tool and Closed Loop Referral for Social Risk Screen and Referral

Completed · Not applicable

Conditions studied: Chronic Disease, Diabetes Mellitus, Hypertension, Congestive Heart Failure

In brief

The overarching goal of this project is to leverage health information technology (HIT) to integrate available digital information on social needs to improve care for racial and ethnic minorities and socially disadvantaged populations with chronic diseases. In the previous phases of this project the investigators developed a social risk score to identify social needs among medically under-served patients with special emphasis on application among African American patients with low income and chronic diseases who face social determinants, risk factors, and needs (SDRN) challenges. The investigators also developed a clinical decision support (CDS) tool to present the social risk score to clinical providers and sought feedback from different users on the face and content validity of the CDS tool. In the current project the investigators will run a randomized clinical trial (RCT) study to pilot test the new risk score and CDS tool in selected primary care clinics at Johns Hopkins Health System (JHHS) and in collaboration with selected community-based organizations (CBOs). This system will help identify, manage, and refer patients with both high levels of disease burden and modifiable SDRN challenges.

Key facts

Study ID

NCT05574699

Run by

Johns Hopkins University

People needed

251

Starts

2023-04-30

Expected to finish

2025-05-27

Last updated by the study team

2026-07-15

Who can join

Age: 18 and older. Sex: any. Healthy volunteers: accepted.

You may qualify if…

• Adult (18+ years old) African-American patients with low income at each clinic

You may not qualify if…

• Children are excluded from this study. Individuals with high levels of income, and those with race other than African American

Where it is running

• Johns Hopkins GreenSpring Station — Baltimore, Maryland, United States
• Johns Hopkins Community Physicians - EBMC — Baltimore, Maryland, United States
• Johns Hopkins Community Physicians - Remington — Baltimore, Maryland, United States
• Johns Hopkins Bayview Medical Center - Comprehensive Care Practice — Baltimore, Maryland, United States
• Johns Hopkins JHOC-GIM Clinic — Baltimore, Maryland, United States

Full record on ClinicalTrials.gov

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